Every Day is Time Out Day

On June 17, 2009 the AORN (Association of periOperative Registered Nurses) honored National Time Out Day.

“National Time Out Day reminds every member of the surgical team how critical it is to take time out for patient safety. Confirm correct patient, correct procedure, and correct surgical site before every invasive procedure.”

With ComplyMD, Every Day is Time Out Day. Our perioperative surgical documentation tool allows physicians and nurses to document in real-time the exact moment of the Surgical Time Out. So, there’s no question if it took place; there’s only evidence that the entire Surgical Team was in agreement at that time of the patient, procedure and site.

Time Outs are critically important in the Operating Suite. “Wrong-site surgery and other preventable mistakes still occur too frequently in US operating rooms.” These mistakes are often attributed to the Surgical Team not taking time to stop and assess the patient’s information and situation, but hurriedly rushing into each case and packing into a day as many surgeries as possible. Care is not always taken to assess the current situation with the current patient and make sure everyone is agreement on information regarding the patient, procedure and site before one incision is made.

This is why in 2004, “Joint Commission released the Universal Protocol urging that a ‘time out’ precede every surgical procedure to verify the correct patient information prior to incision. In support of the Universal Protocol, AORN began sponsoring National Time Out Day to raise awareness about the importance of requiring the entire surgical team—including physicians, nurses, and surgical technologists—to pause before all invasive procedures to communicate as a group and confirm key information about the patient and procedure to help prevent errors from occurring.”

Notice that phrase “key information about the patient” in the sentence above? Patient ID, procedure and site are important to ‘check’ before all procedures. But what about other “key information”? For example, “patient is allergic to penicillin”, “patient with an old MI”, “patient has COPD”, “patient is deaf”, etc. All of these (I would hope) qualify as “key information”. And most all of these would impact the way the Surgical Team cares for the patient, right? ComplyMD offers the luxury of having all of that information right in front of the Surgical Team at the Time Out on one single screen. So, nurses and docs don’t have to spend time flipping through the patient chart to find all the info, it is all captured on one easy-to-read screen (or printout). The ComplyMD Time Out is not only effective but efficient.

Consistent use of ComplyMD’s Surgical Time Out entry field satisfies Joint Commission’s requirement for the Time Out to be documented just before every invasive procedure.

“This year, AORN collaborated with American Nurses Association, the American Association for Accreditation of Ambulatory Surgical Facilities, the Council on Surgical & Perioperative Safety, and The Joint Commission to create a poster to remind professionals, health care providers, and administrators that ‘Every Day is Time Out Day.’”

They also had a National Time Out Day Video Content. To view some of the vidoes that demonstrate the Surgical Time Out procedure, click here and scroll down.

Physician Documentation and Coding: Are Doctors Prepared?

This abstract from the American Journal of Surgery entitled “Surgical residents’ knowledge of documentation and coding for professional services: an opportunity for a focused educational offering” hints at the fact that most physicians are not properly prepared for coding and documentation in the real world of medicine.

We all understand that patient care is the most important aspect of practicing medicine. In Med School, physicians are trained to take care of patients. Many even specialize in a certain area of medicine and take care of certain kinds of sick people.But what about documentation and coding? Why aren’t physicians trained on how to best document what they did on patients? Isn’t good documentation important to continuity of patient care? Isn’t this how they are to defend themselves in a (heaven forbid) medical malpractice case? Isn’t this how they get paid? If physicians don’t know how to document, they’re losing….and its more than just dollars and cents. They’re honestly robbing themselves of being a “Best Pracitces” physician within the healthcare industry. So….WHY is this not taught to physicians in their formal education?

“The purpose of this study was to survey surgical residents and attending for their knowledge of documentation and coding and their opinions about its importance in their training and practice.”

The convenience sample: 60 surgical residents and 46 attendings from 5 surgical residency training programs

“Similar portions of residents and attendings, 82% and 89%, respectively, stated they had not received adequate training in DCPS (documentation and coding for physician services). The vast majority of residents (85%) felt they were novices at coding and billing, whereas 61% of attending stated that they were somewhat knowledgeable.”

So 82-89% of residents and attending do not feel adequately trained in DCPS. So how will they learn? Think about it…CMS, Joint Commission and all the other players have so many rules and regulations that doctors must play by; but the docs are never taught the rules in the first place. It seems that docs have to (a) learn the hard way by making costly mistakes (b) take initiative towards independent training or (c) continue to be losers in the area of documentation and coding.

How Far Does Your Facility Go for Documentation Assurance?

In Hospital Case Management’s recent article “Does Your Documentation Assurance Program Stop Short?” (March 1,2009), the following quote caught our eye:

“If your documentation assurance program focuses on reimbursement alone, you’re not going far enough. With pay-for-performance initiatives on the rise and increasing mandates for public reporting of hospital data, it’s critical that the medical record accurately reflect the severity of illness and the services provided to your patients.”

If we really think about it, the quote above is totally true. Many facilities have implemented Documentation Assurance Programs, such as Clinical Documentation Improvement initiatives. And these programs oftentimes measure ‘success’ in terms of dollars and cents, rather than by quality documentation of severity of illness, continuity of care, level of acuity and risk of mortality.

“Many times, documentation specialists do a great job of picking up the complications/comorbidities (CCs) and major complications/cormorbidities (MCCs) but stop right there and miss the opportunity to add additional documentation, which will affect the drivers of acuity level and risk of mortality.”

Documentation Specialists are trained professionals who are taught to look for those CCs and MCCs. In an attempt to build the best DRG, they must capture these important conditions. But, they shouldn’t just stop when they’ve gotten to a certain DRG level. A good Documentation Specialist will not be focused on getting the patient into the highest paying DRG, but will be focused on painting the most comprehensive picture of the health of each patient.

This is exactly where ComplyMD comes in. In attempt to paint the most vivid picture of (1) the health of the patient and (2) the procedure(s) performed on the patient, we aid physicians and staff in capturing the most documentation about each patient encounter.

American Healthcare – Where Data (Should Be) King

First of all, let me state the obvious. I do not believe that data capture and data analysis should take any form of precedence over quality patient care. This posting is to point out the fact that better data (analyzed data, that is) can improve patient care, even to the point of saving lives. I love this point from the article: “A health care system that is driven by robust comparative clinical evidence will save lives and money.”   

 

So, let’s again visit the great New York Times article about Baseball & American Health Care to find more information about data and documentation within the American health care system.  We see hints all throughout the article about data, data, data……more data (analyzed data) enables better evidence-based methods. We’ve seen the vast improvement in baseball because of their data-driven research and statistics. And we also are able to catch a glimpse of the deficiency of data-driven research and statistics within the American health care system.

 

“Remarkably, a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures. Studies have shown that most health care is not based on clinical studies of what works best and what does not –be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition.”

 

Baseball vs. American Health Care –Who is better at practicing evidence-based methods?

Well, according to this article, baseball is way ahead of American healthcare. The article concludes with:

“American’s health care system behaves like a hidebound, tradition-based ball club that chases after aging sluggers and plays by the old rules: we pay too much and get too little in return. To deliver better health care, we should learn from the successful teams that have adopted baseball’s new evidence-based methods. The best way to start improving quality and lowering costs is to study the stats.”

Sadly, I believe that most Americans would agree that “we pay too much and get too little in return”. Everyone knows that there is room for great improvement in the area of healthcare. Yes, medicine has greatly advanced over the years. But is our health care system really putting its best foot forward when it comes to really making educated, evidence-based decisions?

Good Documentation Means Quality Patient Care

“Too often, doctors are so focused on patient care they sometimes forget to focus on coding and documentation. But if they do not, they won’t get paid for the work they do. Some physicians think documentation takes time away from patient care and that compliant coding reflects nothing about the quality of attention patients receive. These statements are just not true. Good documentation is critically important to patient care.”

Coding Corner. March 2007

Good documentation is not only critically important to patient care, it actually reflects quality patient care. Physicians must ensure accurate documentation of the patient encounter if they want to receive accurate reimbursement…..we know that. But physicians must realize that properly documenting all of the diagnostic and procedural data for a patient actually helps the patient understand their condition and helps their insurance company know more about their patient.